If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases.

Simply stated, you are not the only person who RSVPed “yes” to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you who are nowhere near ready for anything to do with the F word (FERTILITY) but want it in the future (be it near or distant), here’s what we recommend.

Fibroids can be treated medically and/or surgically. Medical treatments include oral contraceptive pills (a.k.a. OCPs or the pill), the intra-uterine device (a.k.a. the IUD), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.

Just like when you’re selecting the OCP you want to marry, you may have to shop around for medical options before you land at your symptom-free spot. While Lupron (a GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come along with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment.

Surgically, the options are limited for women who have not yet had kids. It’s basically a myomectomy or bust. Fibroids have been nicknamed myomas; -ectomy means removal so myomectomy = fibroid removal. While a myomectomy is the only option for you ladies who are not yet ready to part with your uterus, what varies in the myomectomy part is how you “myomectomize.”

The procedure can be performed abdominally (through a bikini-cut incision), laparoscopically (through a camera), robotically (through a robot), or vaginally (no explanation needed!). The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid (s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

As with most things, there are pros and cons to both medical and surgical options. If you like lists (we love them!), here are the important points to note. For most young women who have not had kids but want them in the future, we like to go medical first. Most of the medical options are transient and provide birth control (killing two birds with one stone!). While they will not rid you of your “f”riends, they will decrease many of your symptoms:

Bleeding, check.

Pain, check.

Protecting your future fertility, check.

In many cases, with medical treatment, the fibroids will shrink. Fibroids feed off estrogen, so low estrogen equals famine for fibroids, and hopefully your symptoms will dissipate. If medical management doesn’t do much to alleviate your symptoms, you may have to amp up your treatment to surgery.

Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary.

The only absolute cures for fibroids are menopause and/or a hysterectomy. For women who have baby making on their mind and in their future (be it near or distant), neither of the above is a good option: major con! It is for this reason that we need to find a way to temporize the symptoms until you get the pregnancy process started. We usually recommend starting low and going high, but only if you have to. Give the easy or simpler stuff a shot first before you shoot in out of the park.

Just a side note: while fibroids are pretty pesky for most of us, some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or during pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight.

If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended—no pre-nup here! Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!

http://truly-md.com/wp-content/uploads/2017/03/trulyMD_F.jpg400845truly MD Teamhttp://truly-md.com/wp-content/uploads/2016/07/Truly-MD_Logo-Color-tag.pngtruly MD Team2017-03-20 18:39:162017-04-11 19:49:34Fibroid: What to Do When Fertility Is Not on Your Mind

What’s going on inside your uterus is not a thought that crosses most of our minds on a daily basis. Sure, we are reminded of that organ every month when “Aunt Flo” arrives, but unless you are a medical student, a gynecologist, or a woman who is having problems getting or holding on to a pregnancy, you are probably not all that aware of your uterus. But news flash…the uterus is a pretty important organ with an essential role in reproduction.

This may come as a surprise, but it is actually a muscle. Yup, that’s why you get those intense monthly cramps—and why Advil and Motrin work so well at taking them down a notch. The uterus’s primary job is to carry a pregnancy. And not to get all science-y or medical, but when you think about how the uterus grows and shrinks, thickens and sheds, and carries and delivers, it’s sort of unbelievable. While its marathon is not 26 miles, it actually can go the distance for you several times in your life (depending on how many pregnancies you have). It goes from the size of an orange to the size of a watermelon, all in matter of nine months. Pretty unbelievable stuff!

So, how can you tell if your muscle is in tiptop shape? Obviously, given its location, you can’t stare at it in the mirror as it flexes! The best indication of how your uterus is functioning is the arrival of your monthly “friend.” For women who are not on hormonal contraception (pills, patch, IUD), you should expect a period about every 30 days. While the regularity of your period is not the focus of this piece, and you shouldn’t call your GYN to report a 27- vs. a 32-day cycle, no period or very minimal/light flow might be evidence that something is off inside your uterine cavity. Changes in the character (heavy vs. light) or content (days) of bleeding can also be the signal to seek help.

The uterine cavity (a.k.a. womb) is composed of two layers: the basalis and the functionalis. Think of the basalis as the bottom or the base and the functionalis as the top, or the functioning layer. Every month, when a woman menstruates, she sheds her functionalis, or functioning part. After its departure, the basalis works to replenish or restock this very important important aisle. When damage occurs, the front-line functionalis is the first to take the hit, and as you can imagine, the more soldiers lost, the worse the situation.

And while the uterus takes losing its front line hard, it takes losing its reserve troops (the basalis) even harder. Damage sustained down to the basalis can cause irreparable harm. If you lose the basalis, then not only do you lose that month’s war, but you will also lose all wars in the future. This is because your body will have no way to regrow what has been lost. So bottom line, varying degrees of insult can have varying degrees of injury. Maybe it really is all about the base…

However, while scar tissue in the uterus can translate into no period, what your uterus does is often a reflection of the message that your ovaries (and actually your brain) are sending its way. That’s why women who don’t produce estrogen for any number of reasons (too much exercise, too little food, or even menopause) don’t get a period. No estrogen = no uterine lining. No uterine lining = no period. The estrogen produced by your ovaries works to thicken the uterine lining (a.k.a. the uterine cavity).

So in many cases, women who are not getting a period have a functioning uterus. If the appropriate hormones are delivered in the appropriate fashion, all systems will be a go. Differentiating between the two and trying to figure out where the roadblock is, is actually fairly easy.

While it does take a visit to your OB/GYN and in some cases a fertility specialist, finding out who “did it” is simpler than a game of Clue. Professor Plum in the study with a candlestick it is not. A good history focusing on previous pregnancies, particularly how they ended D&Cs, abortions, retained placenta, and even a C-Section is of the utmost importance. These are the flashing red lights for who may have scar tissue lingering in their uterus and preventing a future pregnancy from occurring. Asherman’s syndrome is the medical term for this condition.

The uterus can develop scar tissue in response to some sort of an injury. Just like any scrape, cut, or bruise, the more significant the injury that caused it, the more significant the scar. While the injury is most frequently a D&C (dilation and curettage) after a pregnancy (be it a miscarriage, an abortion, or a piece of placenta that remained inside after a delivery), it can result from other causes (i.e. an IUD or an infection).

The degree of scarring can be determined by looking inside the uterus with a variety of imaging tests (ultrasound, hysterosalpingogram, hysteroscopy). It can also be suggested by how light, heavy, or absent your period is. For example, if the scar tissue is severe, it could have damaged most of the uterine cavity; this would cause minimal or no bleeding (medically termed amenorrhea). So while the ovaries are sending all the right signals, the uterus lacks the ability to respond to the message.

Even the most extreme cases of scarring can frequently be fixed. You just need to find a good doctor who has a good idea how to navigate the situation. Uterine scarring requires surgery to remove the adhesions (a.k.a. scar tissue) and restore the cavity (a.k.a. womb) to its original shape. While it can make a major difference in your baby-bearing ability, it is a fairly minor procedure, an outpatient procedure that lasts no more than a couple of hours.

The cervix is dilated to allow the placement of a camera. The camera is connected to a monitor (don’t worry; there will be no broadcasting or streaming!), which allows the surgeon a front-row seat to what is going on inside. After identifying the damaged tissue, instruments are threaded through a channel on the camera. The surgeon’s instrument of choice (we like scissors) is used to remove the scarring. Following the procedure, a tiny catheter is placed into the uterus to keep the uterine walls from touching each other for the next five to seven days. Additionally, while the catheter is camped out in your uterus, you will start about a 21- to 28-day course of estrogen and progesterone. The theory behind this cocktail, catheter, and medications, is to go full force on rebuilding a healthy uterine lining.

So does it work? Can even the most damaged of uteri be remodeled? In most cases, yes….mild and moderate cases of uterine scarring are fairly responsive to treatment. Most women go on to have monthly menses (can’t believe you would ever cheer about that, right?) and conceive. Subsequent pregnancies can be at higher risk for placental implantation problems (placenta previa, accreta), but most go the distance without any issues.

Severe cases can present even the most experienced surgeons with a formidable challenge. While it’s often not the removal of the damaged tissue that keeps the red light red, it’s the uterus’s ability to restore good healthy tissue that keeps things at a halt. If damage was sustained all the way down to the basalis, restoring a functioning cavity can be nearly impossible. In such cases, although recreating a functional cavity may evade even the most gifted surgeons, pregnancy can be achieved with the use of a gestational carrier.

Many things in life happen outside of our control. Even the most type-A of us who fight to plan and control every minute (trust us, we get it!) can’t script how our uterus will react to an insult. However, we can outline a plan of attack if something should seem off. If you feel that something is not right, go speak to your GYN, and leave out no details. We need to have all the facts when it comes to your medical history.

Together, we can come up with a road map to navigate a path through even the roughest of waters. It may take a lot of fight, including a few trips to the operating room and a few rounds of estrogen/progesterone, but ultimately with time, the battle can almost always be won.

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain. However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

Increased risk of miscarriage.

Preterm delivery and labor.

Abnormal fetal position.

Fetal growth restriction.

Placental abruption.

Labor dysfunction (and the need for a C-Section).

Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

http://truly-md.com/wp-content/uploads/2017/03/shutterstock_151308128.jpg400845truly MD Teamhttp://truly-md.com/wp-content/uploads/2016/07/Truly-MD_Logo-Color-tag.pngtruly MD Team2017-03-20 18:38:472017-04-11 20:10:48When There Is More Than Your Plus One in Your Pelvis

As parents, we have all been there—the endless, time-stands-still, clock-barely-ticking waiting game. Whether you are waiting for the arrival of your baby or the arrival of your teenager (who is clearly late for curfew!), we have all stood by the door waiting for it to open. The anticipation and the anxiety can be debilitating. Not knowing what is happening and what could happen to your child can be incapacitating. And while we certainly don’t have any ways of making the clock move faster, we do have ways of dealing with the unknown. It’s called limits. We put limits on the situation, our surroundings, and ourselves to limit the negative emotions that can take over your mind and limit your ability to function.

Limit the negative energy: The waiting game is not a solo sport. When you are waiting for news, be it good or bad, it’s nice not to be alone. It’s also nice not to be with people that drive you crazy. Find someone (or someones) who have good juju and can stay by your side as you are standing on the sidelines.

Limit your idle time: When not occupied, your brain can go farther than a trans-Atlantic flight, especially when you are thinking about your children’s health. Your mind can concoct some pretty crazy stories. And while we are not recommending that you do algebra or geometry in your idle time, we are suggesting that you listen to music, read a book, consider meditation, and hop on the phone with one of your friends. Although these modalities won’t change the outcome, they can help speed up the clock and maybe even reset your psyche.

Limit your Google search: On the heels of #2, be skeptical about what your searches reveal. While we too have many degrees from Dr. Google, the Internet can be a scary and sketchy place for advice (minus Truly, MD!). You can take any myriad of symptoms and make them into the Plague. Speak to a professional, and get their educated opinion before you make a diagnosis that is dubious, to say the least.

Set limits for what you can and cannot do: So often, we try and do it all. It’s hard to find one woman who doesn’t want to be Cameron Diaz in There’s Something About Mary. But the reality is that there is no She-Woman (or He-Man, for that matter). We all need help. And we are all limited. Your limitations don’t make you less of a woman, a partner, or a mother. They make you real.

Limit the what-ifs, the should-haves and the could-haves: Life is not lived in reverse. Unlike that car sitting in your driveway, it can only go forward. No matter how hard you want to turn back time, you can’t. At some point, you have to stop beating yourself up for what you “should have” recognized and what you “could have” done. It won’t change what happened; it will only change how you move forward.

Unfortunately, in this game there is no official time clock. There are no periods, no quarters, and no halves. To make it to the end takes fortitude and strength. Parenthood is a challenge. And while we may not be there on the field to cheer you on, we hope that just knowing how many other people have played the same game brings you comfort. You are not playing this game alone!

There are very few areas of medicine that come to a halt or even slow down as we age. Doctors’ visits, medications, check-ups, and those oh-so-pleasant aches and pains just keep on piling up. You need a calendar just to keep track of it all!

That’s why, when your GYN recommends throwing in the towel on Pap smears, it will likely sound somewhat confusing. But the truth is, as we age the frequency with which Pap Smears are performed can be tailored tremendously. In fact, for most of us it can be totally tossed, assuming that your cervix has cooperated and been checked and free of cancer or CIN (the precursor to cervical cancer) for many years. Here’s why.

Pap smear guidelines have changed big time in the past several years. Taking a page out of our friendly Glamour, “yearly is so out,” and every three years or in some cases, never again is so in. The American Congress of Obstetricians and Gynecologists has re-written the Pap smear guideline’s ending, and this is how this story goes…

If chapters 1–5 (that is, ages 21–64 years old) have been pretty clean and clear, once you hit the big 6-5 you can call it quits with Pap smear screening. In the land of cervical cancer screening, clean and clear refer to three consecutive negative (normal) Pap smear results or two consecutive negative co-tests (Pap smears plus HPV testing) within the past 10 years.

To top it all off, the most recent Pap smear test must have been done in the past five years. And while words like co-testing may sound like Swahili, just knowing what to ask your GYN when it comes to Pap smears and when to ask these questions will make sure that they don’t play on and on and on… (#BrokenRecord)

If chapters 1–5 (a.k.a. 21–64 years old) were not totally clean and clear, then you might have to do some editing before you can close the Pap smear chapter. The exception to the “once you turn 65 years old break-up rule” are women who have a history of abnormal Pap smears/cervical screening in the past, specifically a history of CIN 2, CIN 3, or adenocarcinoma in situ. (Think of CIN as a staircase: the higher you get, the closer you are to cervical cancer.) If you fall into this group, you need 20 years of screening after the resolution or treatment of the CIN 2 and beyond, even if it takes you past the 65-year-old mark.

And while there are likely some terms in here that are making you do a double take (a.k.a. CIN and adenocarcinoma in situ), knowing the specifics is really secondary to simply having the knowledge to start the conversation with your doctor. For example, if you know for sure that you have never had any or all of the above (CIN 2, CIN 3, or adenocarcinoma) and your doctor is still performing Pap smears on you at 67…it’s time to start asking questions.

If you had a hysterectomybefore reaching the magic 6-5, you might be able to bid Pap smears adieu at an even earlier age. In fact, women who had a hysterectomy with removal of the cervix and never had a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer can stop Pap smears immediately following the removal of the uterus. Those that had a hysterectomy with removal of the cervix and have had a history of CIN 2, CIN3, adenocarcinoma in situ, or cancer must continue with Pap smears. Again, you will need 20 years of screening after the resolution or treatment of the CIN 2+ before you can call it quits.

Last, if you had a hysterectomy and kept your cervix (a.k.a. a supracervical hysterectomy), you can’t bid your Pap smears a fond farewell until you hit 65 (or longer, depending on your history). And while you might be breaking up for good with your Pap smear, let us be very clear that you are not saying goodbye to your GYN. There are many more topics and tests that are checked at your yearly visit (as well as a good old fashion chat!). Maintaining an ongoing relationship with your GYN is important—remember, you have many reproductive organs other than your cervix!

Getting the phone call that you have flunked (even worse, scored a “zero”) yours or your guy’s semen analysis can be pretty devastating. The rush of emotions that runs through your head is more extreme than the waves seen in the famous Eddie Aikau surf competition. And when you realize what it could mean for your fertility, it’s like wiping out and then getting worked by the wave all in one go.

The first thing you should do is take a deep breath. One semen analysis doesn’t mean it’s the end of the road. However, if the repeat test confirms that there is nothing there, further investigative work needs to be done.

The medical term for no sperm is azoospermia (this is different than aspermia, which is the absence of sperm and seminal fluid at the time of ejaculation). Because men with azoospermia frequently have normal ejaculates, they can go undiagnosed for years—sperm is microscopic, so unless someone is looking really close at it with a high-powered lens, you can’t see those swimmers.

While azoospermia is every guy’s fear, it is actually pretty rare, phew! Only about 1% of all men have azoospermia (it is higher in couples that suffer from male factor infertility, and in these patients can be as high as 15%).

If your guy is one of the unlucky 1% and are searching for answers and information, we recommend thinking about it in the following way: Imagine you have three connecting flights coming into the airport at the same time. One is from New York City, one is from Boston, and one is from Atlanta. They are all connecting through Chicago to LA—all the passengers will be on the same second flight although they originated in different places. Azoospermia is the end point for post-testicular, testicular, and pre-testicular conditions; they all arise from different diseases (or departing cities) but ultimately land in the same place.

From City A, we have post-testicular azoospermia. (The testicles are making sperm, but there is a blockage preventing it from exiting and getting in the ejaculate). From City B, you have testicular azoospermia. In these cases, the exit pathway is clear, but the testicles are not producing sperm. The latter or “B” cases are generally much more difficult and often require donor sperm. From City C, we have pre-testicular azoospermia. Here, the testes are ready and waiting, but the signal is either not coming down correctly from the brain OR, due to underlying endocrine (hormonal) problems, the testes have failed to produce sperm.

After the initial diagnosis of azoospermia has been confirmed (two azoospermic samples where the seminal fluid is centrifuged for 15 minutes at super-high speed), your guy is usually sent to a urologist (specifically, one that specializes in male factor infertility) to see which “city” you have departed from. Through a full review of the medical history, a physical exam, an ultrasound, and lots of blood work, the urologist can usually get to the bottom of why there does not appear to be any sperm in the ejaculate. The tests that your partner will go through in many ways will mimic what you have been asked to do—we will check his FSH , LH , testosterone, thyroid hormone , and prolactin. We will also do extensive genetic testing to see if we can identify the problem.

It’s very important to do the full genetic work-up because there are often abnormalities which, if identified, can be passed on to future generations. Not good. While you may not know exactly what or why we are testing your plus one for, you should make sure that a full testing panel is performed. You should also make sure that you sit with both yours and your partner’s doctor so that, together, you come up with the best plan for you as a couple.

We don’t expect to make you urologists or even sperm connoisseurs, but we do want to help you better understand the potential answers to the azoospermia conundrum. We are going to give you a very basic review (and no quiz!) to help you better answer the questions that are likely racing through your head the minute you get the news.

Flight A = Post-testicular Azoospermia: Here the problem happens not in the testes but after the testes. Going back to basic bio, the problems happen in the ducts that connect the testes to the urethra (think vas deferens). It can also occur from ejaculatory dysfunction. We don’t want you to cringe or try and picture it in your head, but the visual that you should have is that, in most cases, the testes are making lots of good-quality sperm. The sperm has just been stranded on an island waiting for a rescue boat (or connecting flight!). The rescue boat is either a surgical procedure to unblock the blockage (basically re-open the road), or if the road is totally beyond repair (think most major cities highways), then we go above the blockage (a.k.a. the testes). The latter is called a testicular extraction of sperm (nickname TESE or TESA). Surgically, a urologist will enter the testes and extract sperm (ouch, that doesn’t sound fun—don’t worry, you will get anesthesia!). This sperm can be used to fertilize eggs in an IVF cycle. The rescue mission is usually successful, and the resultant pregnancy rates are often quite good. Bonus is that we can often freeze sperm for use in the future (like years later) IVF cycles. Obstructive azo (as we fertility doctors call it) occurs in about 40% of men with azoospermia.

Flight B = Testicular Azoospermia: When the testes themselves are the cause of no sperm, it can be a bad situation. Like planes in a blizzard, nothing is taking off for a long time. Despite our advancements and flashy technology, much like ovarian failure, we cannot overcome testicular failure. Think of testicular failure like premature menopause; for some reason, the testes stopped making sperm long before their time. We usually know that we are dealing with option B (as opposed to A) because the FSH is elevated and the testosterone is low. Much like ovaries that are sort of done, when the testes stop working, testosterone (which is made in the testes) stops being produced. Last, in a physical exam, the testes are small (medically termed atrophic), and we have a pretty good idea we won’t find sperm. However, with this being said, barring a serious genetic condition, many urologists and fertility doctors will still go for the testicular sperm extraction surgery to confirm that we are truly running on empty. However, it is important to note that many testicular cases of azoospermia are a result of genetic abnormalities. Unfortunately, we don’t really know many of the genes causing the significant decline in sperm production. Therefore, if the sperm is successfully extracted and used to fertilize eggs, you could be passing some “bad fertility/sperm genes” on without even knowing what they are. While we are not saying you should not use the sperm, we are recommending that you chat with your doctors and a genetics counselor first.

Flight C: Pre-testicular azoospermia causes of azoospermia are the rarest. They are most frequently due to hormonal abnormalities that result in testicular failure or mixed signals coming down from the brain. If the brain is on a break and does not appear to be doing its job (or something is impinging on its ability to do its job), we can usually fix that. With the help of medications, we can get things back on track. It may take several months to get the engines going again, but it will get there. In fact, if sperm production can be restored, your guy may not need any surgical interventions, and while you still may need our help to get pregnant, you may not need IVF.

There is almost nothing more devastating than hearing that you or your plus one has run out of eggs or sperm before your time was supposed to be up. It’s unfair, it’s frustrating, and it can be downright infuriating. While using our services or donor sperm (if it comes to that) is likely not how you envisioned making a family, our goal is to make you a father. We can most certainly do that; even when the waves seem big and you can’t imagine riding another one, we promise you can. Just hang ten, and let us guide you to calmer waters.

Unfortunately, it is more the norm for us to see or hear about couples (and individuals) that have undergone years of fertility treatments without success. Month after month, they take medications, inject themselves with hormones, and hold their breath as they wait for the pregnancy test results. For many of these patients, be it for medical reasons, financial reasons, insurance reasons, or misguided reasons, there is little that is changed between the negative cycles. We like to call this the merry-go-round effect: couples/individuals who continue the same ineffective treatments month after month without redirecting or reanalyzing the situation. It’s a bad situation that we want to help you change.

Let’s face it: after the same treatment, be it timed intercourse, oral medications, inseminations, or IVF, has failed continuously, something needs to change. Whether it be moving on to more aggressive treatments (or, as we say, stepping up the ladder!), tweaking the current protocol, or seeking a second opinion, you need to shake things up. There are many available fertility treatments that can be, and likely should be, utilized.

A patient-doctor relationship should be a partnership with give and take, as well as back and forth. Gone are the paternalistic days of medicine where the doctor speaks and the patient listens. Treatment decisions should no longer be dictated, but rather, discussed. If this is not happening for you and you find yourself in the merry-go-round rut, then you need to put the brakes on. Make a phone call, send an email, or sit down with your doctor to review your case. Bring your list of questions, and ask away.

If you don’t like the answers, don’t be afraid to take them and your struggles elsewhere. At some point, you have to either ask the attendant to stop the ride or simply hop off. Eventually, circling in the same direction stops being fun, exciting, or promising; it also makes you nauseous, dizzy, and loopy!

So be your own advocate, and shut this ride down. The park is huge, with so many more rides and adventures to explore.

http://truly-md.com/wp-content/uploads/2017/03/shutterstock_434961442.png400845truly MD Teamhttp://truly-md.com/wp-content/uploads/2016/07/Truly-MD_Logo-Color-tag.pngtruly MD Team2017-03-08 02:00:082017-03-17 19:48:18Round and Round You Go: We Hope It Stops Where You Want to Go!

Admission….despite endless years of schooling, training, and then more training, there is a lot that doctors don’t know. We wish we did, because inherently it is in our nature to heal and to fix, but unfortunately, there are many questions in medicine that remain unanswered. Despite our fancy tools (and trust us, there are a lot!), we still lack that crystal ball. And not only can we not diagnose everything, but we also don’t always know why somebody gets a disease. The latter is super frustrating.

How does the woman who eats only organic, exercises daily, and has never smoked get breast cancer? How does the man who has never eaten at McDonalds and spends two hours a day on his treadmill have a heart attack? It simply does not make sense. Therefore, what we do know and what we can stop we want to share or, rather, shout as loud as possible! We want to make sure you know what you can do to decrease your risk, to stay healthy, and to prevent a bad event.

While most cancers are not preventable, for the most part, cervical cancer is. The majority of cervical cancer is caused by a virus (the human papillomavirus, or HPV): not the same virus that causes the common cold or a stomach bug but a virus that can infect the cervix and, if not treated over several years, lead to cervical cancer. Now, just like there are many different types of viruses that can ultimately lead to the same end point (e.g., the common cold), there are different strains of the HPV virus (120 to be exact!). And again, in the same vein as the common cold, some strains are going to knock you on your behind more than others.

So while there are 120 different viruses, about 40 HPV types (medically called genotypes) are sexually transmitted, and 13 have been shown to cause cervical cancer. And to whittle it down even further, about 70% of all cases of cervical cancer are caused by two HPV genotypes, 16 and 18, and 90% of genital warts are caused by HPV genotypes 6 and 11. Therefore, if you can avoid ever being infected with HPV, you will nearly eliminate your chances of getting cervical cancer. Additionally, because regular Pap smears will almost always pick up abnormalities on their way to cervical cancer, if you do get or are infected with HPV and develop cervical abnormalities (a.k.a. abnormal Pap smears), good screening and frequent visits to your gynecologist can ensure a bad thing doesn’t get worse.

But pap smears and the further testing that is required (colposcopy, LEEP, and the cold knife cone) when one is abnormal can be really scary (these procedures can translate into taking off a piece of your cervix). Additionally, it can become a tedious chore (you have to be seen every six months, and who has time for that?). If cervical surgery is required, it can put you at risk for a preterm delivery in the future. By avoiding an infection with HPV, you could avoid a trip on this unhappy merry go round. Although abstinence would do the trick, while we are mothers, we are not ignorant! From teens on up, girls are going to have sex; we do our best to educate and advise, but it’s going to happen. Therefore, the next best thing to do is to prevent the transmission of HPV. This can be done by a vaccination—just as we prevent the measles, the mumps, and polio through a vaccine, we can now prevent the spread of HPV. By vaccinating girls (and boys!), ideally before their first sexual encounter, we can significantly reduce the incidence of cervical cancer, anogenital cancers, oropharyngeal cancer, and cervical warts (now, that’s one heck of a shopping list—not one thing on there we would like to acquire!).

So currently there are two vaccines that have been approved by the FDA to work in preventing HPV infection. One protects against the big four genotypes of HPV (6, 11, 16, 18), while the other only protects against two genotypes of HPV (16 and 18). The latter is only approved for administration in females while the former (four) is approved for administration in females and males. The good news is this: if either is given in the right way—three doses, six months apart in girls (and boys) between the ages of 9–26 years old before they have been sexually active—it works really well. Under these guidelines, it’s nearly 100% effective.

In order to hit all these points, you need to start vaccinating girls (and guys) at a young age. In fact, the target age to start is 11 or 12 years old. If you miss the window and sexual activity starts before you start vaccinating (or you don’t start vaccinating until a later age), it is still worth a shot! While you may have already been infected with HPV, it could be just one strain (let’s say 6). That means that, while the vaccine won’t protect you from 6 or the goodies that come along with it (hello, genital warts), it will protect you from other strains (those that cause cervical cancer). So roll up your sleeve, and start the series, because it is still worth it.

Points worth mentioning…the vaccine can be given to girls as young as 9 and as old as 26; the window is large enough that you shouldn’t miss it. If you are late for a shot (say, you forget to come in 1–2 months after the first dose and roll into your GYN at month three) you are still okay to proceed. Once you start the series, no matter how long it is paused, you can finish it.

The only exception is pregnancy. While there is no definitive data to show that the vaccine is harmful in pregnancy, OB/GYNs recommend waiting to finish the vaccine series until your nine months are up. Breastfeeding women have the all clear to take the vaccine, as the HPV vaccine is inactivated (no live virus).

It’s a small price or “prick” to pay to protect yourself against cervical cancer and genital warts. Neither is pleasant, and we can assure you won’t be missed by anyone. While you still need Pap smears and still need to visit your OB/GYN for checkups, you can check some pretty unpleasant gynecologic conditions off your list if you follow the schedule. Despite the negative hype, vaccines are sort of amazing; we don’t get polio, we don’t get the measles. Now (if done in the way it’s prescribed), we won’t get HPV. This is just another example of how preventative medicine can be effective. So take yourself or your daughter and/or son to the OB/GYN. You don’t want to miss your window, for many women won’t get another chance.

To all you cyclists, runners, rock-climbers, and challenge-takers, the hill can be a real beast on the way up. Pushing towards that summit can be exhausting and physically painful. However, once you peak and start the descent it’s a feeling like no other. You did it. Now, enjoy the reward of the downhill. Much the same can be said of the post-retrieval bloat, discomfort, and weight gain. After you reach the peak, it is smooth sailing.

Women are often shocked at how much worse they feel after the retrieval than before. While the swelling, heaviness, and blah feeling are definitely there before the retrieval, they’re about 10 times worse after! When we tell patients this, they’re often shocked. How can that be? You’re taking the eggs out; shouldn’t the symptoms get better? No, in fact, they get worse!

Let’s do a little Bio 101. Eggs are housed in fluid-filled follicles, and follicles live in the ovaries. Many follicles = big ovaries. Seems simple. During the egg retrieval, we drain the follicles of their fluid, and within that fluid comes the eggs. However, after the follicles are drained of fluid they fill with blood. They become corpus lutea (plural for corpus luteum—you learn something new every day!). The CLs (everyone needs a nickname) make a lot of hormones that can make you feel not so hot (#progesterone). Additionally, they often fill with blood. As a result, the ovary stays enlarged, and your belly stays big. This hormone soup keeps the ovaries large, the belly filled with fluid, and you feeling like a balloon at the Macy’s Thanksgiving Day Parade!

Okay, so I am going to feel awful…how long will this go on? The length of the post-retrieval to menses (a.k.a. period) varies based on the trigger shot you were given. Women that get straight HCG or ovidrel will feel the bloat for about 12–14 days. The HCG hormone in both of these formulations is like gas for the ovaries—they keep the ovaries charged and the hormones pumping. And although the symptoms will improve significantly after about seven days, you won’t be back in your skinny jeans until you get a period about 14 days later.

If you were given a Lupron or Lupron +HCG trigger, your period of pain will be protracted (that’s why we give it!). Most women will start to feel better about three to four days after the retrieval and get their period about seven days later. For the majority of women, the blah-blech feeling will steadily increase post-retrieval until you hit the peak about three-ish days later; the summit will be higher and the climb further if your trigger medication was straight-up HCG with no Lupron chaser.

When embryos are transferred back into the uterus during the stimulation cycle and you get pregnant, it’s like you are racing the Tour De France rather than your local 10-miler. The pregnancy will make HCG, and the HCG will make that hill way longer. You won’t recover for several weeks into the pregnancy. It is for this reason, along with new data on the OB benefits of fresh cycles, that we push you to press pause and freeze the embryos. Trust us. Your body, your ovaries, and your brain will thank us.

They say life is about the journey and not the destination. And we mostly agree with that. However, in terms of ovarian stimulation and the aftereffects it’s all about the destination. The climb up will likely not be fun. Keep your eye on the top, and take one step at a time. We’re right there beside you, cheering you on!

http://truly-md.com/wp-content/uploads/2017/03/shutterstock_373307200.jpg400845truly MD Teamhttp://truly-md.com/wp-content/uploads/2016/07/Truly-MD_Logo-Color-tag.pngtruly MD Team2017-03-08 01:57:072017-03-20 18:40:00What Goes up Must Come Down: What to Expect AFTER an Egg Retrieval

Praying to the porcelain god, hugging the bowl, or tossing one’s cookies—whatever you want to call it, vomiting is not fun. In fact, it may be one of the most un-fun bodily processes. Add to that unremitting nausea, and you have got yourself quite a pair. And while this dynamic duo is usually only welcomed after select occasions—a stomach virus, food poisoning, or after a serious night out on the town—in pregnancy, it can be a daily event. The hormones secreted by pregnancy (a.k.a. hCG and estrogen) can make you pretty sick—so sick, even getting out of bed to brush your teeth may seem impossible.

Nausea and vomiting in early pregnancy is VERY common. Nearly 75% of women will feel nauseous or vomit at some time during their pregnancy. However, the extreme cases (medically termed hyperemesis gravidarum) are VERY rare. And although nausea and vomiting in pregnancy can happen to any lucky lady, it is more likely to happen in women who are pregnant with multiples (more placenta = more hormones = more nausea), have a history of hyperemesis in a past pregnancy, have a family history of hyperemesis, are prone to motion sickness, or have a personal history of migraines.

Although persistent nausea and vomiting won’t kill you, it will likely make you feel like you’re dying. You can’t work, you can’t work out, and you can barely move. So, what can you do to give the baby barfing the boot?

First, if possible, start taking a prenatal vitamin at least three months before you conceive. Some prep time can help prevent the nausea that women can experience with prenatal vitamins.

Second, try to limit the time you spend around smells that make you sick (goodbye, garlic!).

Third, trade in three large meals for six small ones. The less you need to digest, the less likely you are to lose it!

Fourth, stay away from spicy and fatty foods, and fifth, shelve any pills with iron.

Last, think about investing in ginger pills. Not only has ginger been shown to be beneficial for your immune system, but studies also show that it may be the secret to curtailing your nausea. And although the medical jury is still out on acupressure, acupuncture, and electrical nerve stimulation to the inside of the wrist, it can’t hurt to try.

When simple measures fail and you are still BFF with your toilet bowl, it’s time to bring out the big guns (a.k.a. medications). Your OB will likely start with something like vitamin B6 or vitamin B6 plus doxylamine. If this doesn’t do the trick, they may amp it up with prescription anti-nausea medications. However, before you go this route, it’s important to have a chat with your OB about what’s coming up and when before you take anything else down.

If this still doesn’t cut it and you’re cutting weight like a wrestler before a big fight, your OB may consider admitting you to the hospital for intravenous nutrition. Severe causes call for serious measures. Nutrition can be delivered through an IV if need be.

Although it is very rare for this fight to go the distance, if you find yourself still battling nausea in the second trimester, consider adding an antacid or reflux medication. Often, women start to experience reflux in the second trimester. As your little one grows, so does your uterus. As your uterus grows, the space between your uterus and your upper abdominal organs (think stomach) shrinks. Pressure on the stomach can cause things to come back up (a.k.a. reflux), which can lead to nausea and even vomiting.

In cases where nausea and vomiting start after nine weeks or there are other atypical symptoms (abdominal pain, fever, headache), it’s important to reach out to your doctor—ASAP. Not all nausea and vomiting in pregnancy is normal. Sometimes it can indicate that something serious (appendicitis, kidney infection, kidney stones) is going on.

The good news about nausea and vomiting is that, while it can make you miserable, it usually doesn’t do anything miserable to your body or to your baby. Even when the only thing your stomach can stomach is saltines and ginger ale, your baby will be just fine.

Whether you call it “puking,” “barfing,” “hurling,” or “vomiting,” we call it no fun. But it will pass, and we will do our best to get you through it, one day at a time!

http://truly-md.com/wp-content/uploads/2017/03/TrulyMD_toilet.jpg400845truly MD Teamhttp://truly-md.com/wp-content/uploads/2016/07/Truly-MD_Logo-Color-tag.pngtruly MD Team2017-03-08 01:56:462017-03-20 18:40:04The Lowdown on What to Do When You Can’t Get Anything to Stay Down: Nausea in Pregnancy